06 May 2008

We all have our little tips and tricks that we have learned over the years, and this is one that really baffles me as to why it has never caught on more.

In residency, we used to have to put in central lines every single shift, often more than one per shift. This was ain an inner-city training program where IV drug use was endemic. So we devoted a lot of time and energy to getting good (and fast) at putting in lines. Now that I'm in the community, I wind up putting in lines a lot less often -- maybe once or twice a month, at that. But I did enough of them in residency that I'm still confident that I am good at them.

While I was training, I spent a lot of time struggling with the standard subclavian/internal jugular approaches. Not that I had complications or couldn't do them, but I was just never comfortable with those approaches. One day, an attending taught me the supraclavicular approach pictured above, and it was so simple, so fast and easy, so safe, that since then I have done almost 100% of my lines that way. Also, it's a great trick to have up your sleeve in the difficult line patient, because it's not commonly used. All the other line sites may be scarred down and inaccessible, but this one is usually still open, and you wind up looking like a hero, getting the line in the "impossible access" patient.

But it seems like almost nobody else uses this approach. Until recently it wasn't even in Robert & Hedges (the procedural bible for ER docs), and there's scant literature on the technique. Every so often I meet someone who does their lines the same way, and it's like meeting another member of some little secret society: "Really, you do these, too? Cool!" And we marvel at how clever we are and why doesn't everybody else do them?

So, I ask the docs reading this: of central lines you do (above the waist), what approach do you typically use and why?

16 comments:

Few people really NEED a central line in the ER (at least the ones where I work). They need IV access, and once that's accomplished we can usually stabilize patients who are going to be able to be stabilized.

In the absence of sepsis (in which case the benefit of the oximetric IJ central venous catheter has been pretty clearly established), most other indications are more for convenience than necessity.

If the nurses can't get a peripheral IV, I'll usually place an 18-20g EJ which is generally sufficient. Failing that, I'll typically place a triple lumen or large bore introducer in the femoral vein.

If the patient is sick enough to require a central line, they aren't going to be getting out of bed for a couple of days anyway.

I agree that most people can be adequately resuscitated without a central line, although unless I just absolutely don't have the time I try to place one after most of my intubations because they invariably need multiple meds hanging at the same time: saline, antibiotics, propofol, insulin, gi bleed stuff, pressors, etc.

As far as approach, my general rule is a skinny person gets an IJ and a fat person gets a subclavian. This is a function of how well I can make out their neck landmarks and how much soft tissue is inbetween their clavicle and lung.

I'm new enough that the supraclaviclar is a recognized approach (at least in emergency medicine. A friend of mine in residency put in a supraclaviclar line, where it was later removed by the ICU attending because he wasn't "comfortable" with it.) But I've never put in a line this way -- I got too comfortable with the traditional methods and unfortunately never went out on a limb to learn it. Too bad, I think it is a nice tool to have in your pocket.

99% of the lines I do are left subclavians. Our crit. care guys love left subclavians, and they really push us to do those. It also helps that our sepcaths we use for the septic guys (SCVO2 monitoring) are 20cm caths, so it really works well from a left sided approach.

I'll add, though, I did do an IJ today because the lady had a pacer on the left, and an infected Hickman on the right, and wasn't going to get anywhere near that.

I'll do about one every other day or so.....like I said, our crit care guys like their intubated patients to be lined before they hit the ICU.

An alternative approach is to place the line under ultrasound guidance. You can clearly see the vein (and artery) while introducing the needle. Many places have portable devices which are the size of a pulse oximeter. See one here:

I worked in vascular ultrasound and I assisted on a number of access issues in ICU/NICU like clinical images said. It is pretty easy -- I remember one where I wish they would have called. The ER doc put a line in the kids common carotid artery (he was in arrest, so no pulsing).

The kid ended up with a long mobile thrombus (that was initially mistaken for a carotid dissection by both me with U/S and the radiologist on CTA) and had surgical thrombectomy. That could have been avoided if the ER doc would have just called me to image for insertion... (hindsight 20/20 of course).

No doubt they're pissed. But what about this, which says that femoral catheters should be avoided, when possible. Jugulars should also be avoided. Subclavian is recommended (no mention of supra), where possible.

If it's heart block and the patient needs a permanent pacer (eventually), the IJ or supraclavicular approaches are usually prefered because they spare the subclavian or axillary venous access for later permanent pacer implants. But hey, if you're more comfortable with one approach over the other, then use what works for you (like Clinical Cases and Images, I like the US-guided approach if it's available) - just my $0.02.

That approach places you at increased risk of injuring the brachial plexus as it emerges from between the 1st and 2nd interscalene muscles and dives toward the axilla, very near where you are placing that line. The best approach is with ultrasound guidance and is on the verge of being considered standard of care. Brachial plexopathy is a complication worth avoiding.

Nathan had several placed. I lost count. He had at least two tunneled from up in the neck (maybe three...I'm thinking two on one side and one on the other) and one or two tunneled from his chest. These weren't "emergency" in the sense that they were all placed in surgery for planned chemo use. One of the surgeons explained how happy he was that his colleague had placed the other lines in the neck because he was more comfortable with the chest and had more options to work with. So, I guess variety is good for keeping options open. From the parent of the child aspect, I didn't really see a difference in preference. I'm sure some would rather not have that visible scar up on the neck, but I never really thought much about that stuff.

I love fact-free based statements like "ultrasound guidance ... is on the verge of being considered standard of care." By whom and based on what evidence?

I will wager to you that 95% of the lines performed in the US, by EPs and otherwise, are performed without guidance. Don't get me wrong -- it's a great skill to have, and can make difficult lines easier or can even make the impossible line possible. Given that the M&M for blind central line insertion is low -- very low -- it's hard to conceive of any requirement that all lines be performed with ultrasound, which is the necessary consequence of your assertion.

In order for this to become a standard of care, it must have better evidence that it is a superior method, better evidence of improved outcomes, and more widespread adoption. None of those three criteria have been met.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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